Don't ask, don't tell?

The ethics of organ donation from executed prisoners

There are reports of a growing trend in which the organs of prisoners executed in China are used for transplants. As many as 5,000 organs might be available this year alone, and many will go to Americans. The practice raises serious ethical questions about whether the prisoners actually give consent for the donation of their organs and, if so, whether the decision could possibly be free and not coerced.

There are even reports that some of the donors were innocent and were pressured into a confession and subsequent execution. It is unclear whether such donations would meet the standards for consent in the United States and elsewhere -- U.S. prisoners who are executed are not offered the option to donate their organs after they die.

These overseas transplants allow patients who might otherwise wait many years for an organ to receive one more quickly, and many return to the United States for subsequent medical treatment. Do the benefits of such transplants outweigh the dubious circumstances under which they become available? In the end, what responsibilities do patients, physicians and governments have for making sure the organs used for transplant are ethically obtained?

Turning a blind eye?

Physicians whose patients seek overseas transplants face a dilemma: By treating patients who have received organs from executed prisoners -- especially if they are aware of the circumstances -- doctors are tacitly accepting, if not endorsing the practice. But if they refuse to treat patients upon their return, they are failing to provide the ongoing medical care that their patients need, which is their moral obligation.

Doctors are not required to provide treatment they perceive as immoral, though they are then required to refer the patient to another physician who can provide adequate care. In the end, it will be up to the individual physician to decide whether to treat patients who may have received organs from executed prisoners, at least until there is direction from professional societies or the government.

But physicians cannot turn a blind eye or pretend that the practice does not raise concern. At the very least, they must discuss it with the patient to help ensure that such transplants are ethically acceptable.

Patients also must take responsibility for determining where the organs will come from and how they will be obtained.

Choosing not to know does not make the donation and transplant more acceptable -- recipients still would be complicit in making use of unethically obtained organs. This is the concept of "dirty hands," in which it is unethical to take advantage of the wrongdoing of another, even if you weren't involved.

Just as physicians should not turn a blind eye, neither should prospective organ recipients.

International problems, solutions

It is clear that desperation and a short supply of organs are the motivations for patients' traveling far from home to receive a questionable organ. But this is evidence of the problem rather than a solution. Disparate policies among countries both allow and encourage patients from one country to seek organs offered in another.

Even if organs are collected ethically overseas, access to them is restricted to those with the means to pay for travel, medical care, hospitalization and other costs. So the additional organs are not equitably distributed -- people with greater wealth have greater priority. And if the demand for organs is great enough to lure patients overseas, living donations cannot be far behind -- a recipe for the exploitation of people desperate for money by those who are desperate for organs.

Addressing these issues will require a concerted international effort by all those involved. Otherwise there's the prospect of a grisly market in organs, and a world in which some countries will collect and distribute organs by whatever means available. This is a world we must work hard to avoid.